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Hi, I'm Krisi Brackett, MS SLP/CCC this blog is dedicated to current information on pediatric feeding and swallowing issues. Email me at feedingnewsletter@gmail.com with questions.

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Feeding Therapy Case Study

March 20, 2016 by Krisi Brackett 6 Comments

feed 44Feeding Therapy Case Study on Randomizing Meals to Facilitate Intake in a Bottle Dependent Child

By Ben Zimmerman, Feeding Clinic of Los Angeles

ben@pediatricfeeding.com, www.pediatricfeeding.com

 

Michael was a 4-year-old child diagnosed with autism.

 

He had an unremarkable medical history. Prior to coming to the clinic he would only consume bottles of formula. He would drink 6-8 bottles per day of concentrated formula. He would not drink from other containers nor would he drink other liquids. He also did not consume any solids.

 

He was seen for four weeks in total. Treatment was three times per day, five days per week.

 

The first week consisted of introducing solids to him. Purees were used for two reasons: (1) he had never chewed on a solid, which could make sessions dangerous because poorly chewed solids can be a choking hazarding (2) more trials can occur per session because time is not wasted on chewing.

 

Four foods, chicken, green beans, macaroni and cheese, and applesauce, were randomized throughout the meals and week.

 

Introducing solids consisted of presenting a bite, while simultaneously verbally prompting him to take a bite. The bite was presented to the top lip until there was a mouth opening, and then the bite was deposited in the mouth. The bite would not be deposited in cases of gagging, coughing or vomiting, but were put in during all other openings. Each meal had a time cap of twenty-five minutes, and volume of seven ounces of food. The session would end when either the time cap had elapsed or the volume was consumed, whichever occurred first.

 

Week 1

week 1

The chart above shows how the time between presentation of food and the bite being taken decreased. During the first session bites were taken an average of ten seconds after food presentation. By session three, bites were taken on average after three seconds, and by session five they were stable at about one second.

 

Week two of treatment involved the introduction of new foods. Bites were presented with the same protocol as in week one. Four novel foods were presented in each session. Volumes of each food were held constant at three ounces each, including all food groups in the meal. Randomizing foods in this way, instead of focusing on one or just a few foods helped to generalize eating across all foods, as can be seen in the next graph.

 

Week 2

week 2

There was a general trend in latencies dropping over time. By the tenth session of week two, latencies were stable at or near one second. This graph shows that eating was conditioned to occur at short latencies across all foods.

 

Generalizing meals to other settings serves the function of not only strengthening eating behaviors, but also ensuring that eating would take place across all settings (no matter the food), including the child’s own home environment. Week three consisted of randomizing nine settings across the fifteen meals throughout the week. All other variables were held constant, including randomizing the same foods used in week two. Settings included the park, playroom, different treatment rooms, hotel room, and hotel lobby.

 

Week 3

week 3

There was an initial spike of refusal, which was followed by a sharp downward trend. By session 35 latencies were at or near one second.

 

Week four consisted of training primary caregiver to feed with random foods and random settings. This would ensure that feedings across settings and foods would only take place in the context of the therapist, but also ensure that feedings take place with the primary caregiver.

 

Week 4

week 4

There was a downward trend after session 47. Most meals thereafter were at one or two seconds, except for a spike in latency for sessions 52-53. Primary caregiver reported that eating continues at low latencies across foods and settings. This was reported four months subsequent to completion of treatment.

 

Data was collected by videotaping all sessions. Two data collectors independently took data while viewing video footage at separate times. Inter-observer reliability was measured at 86%.

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Filed Under: Behavioral Intervention, Feeding Treatment Tagged With: feeding therapy

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  1. JHaun says

    March 21, 2016 at 11:36 am

    Did the child do any independent feeding by the end of the 4 weeks or was everything fed to him by the therapist or parent?

    Reply
  2. Ben Zimmerman says

    March 22, 2016 at 5:25 pm

    Since eating puree was something new for this child, we decided to put that in stone before implementing self-feeding. If something went wrong, it would be easier to address as a non-self-feeder.

    In this case, we waited roughly two months after taking the protocol home to implement a self-feeding protocol.

    Reply
  3. Jenny says

    March 29, 2016 at 8:19 pm

    Was any investigation done to determine why he hadn’t transitioned to solids? Oral motor issues? No mouthing as a baby? Tongue tie? Traumatic experience? Is there any thought about what flavors the child might enjoy more than others? Curious about how this child had been introduced to solid food in the past.

    Reply
    • Ben Zimmerman says

      March 29, 2016 at 8:31 pm

      The parents had been going to OT, speech and GI prior to initiating therapy with me.

      -There were no physiological issues.

      -Mom reported that OT said that there were sensory issues.

      -No specific event was ever linked to the feeding issue. Mom did report that issues began during infancy.

      -Child would not consume anything outside of milk/ formula. Other flavors were introduced in the past, so I had no thoughts on flavor preference when I started.

      Reply
      • Ben Zimmerman says

        March 29, 2016 at 8:43 pm

        Flavor preferences/ dislikes were evident after more than 30 foods had been introduced.

        I don’t remember offhand which specific ones were non-preferred, but the number was not more than a handful.

        Reply
  4. Ben Zimmerman says

    March 29, 2016 at 8:53 pm

    I don’t know if it adds anything, but this child was nonverbal. He had a some sort of a device w/ buttons that he used for communication.

    Reply

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